HIV and dyadic intervention: an interdependence and communal coping analysis

'If there is joy… I think it can work well': a qualitative study investigating relationship factors impacting HIV self-testing acceptability among pregnant women and male partners in Uganda

OBJECTIVES

Secondary distribution of HIV self-test (HIVST) kits from pregnant women attending antenatal care (ANC) to their male partners is shown to increase HIV couples testing and disclosure, and is being scaled up in sub-Saharan Africa. Understanding couples-level barriers and facilitators influencing HIVST uptake is critical to designing strategies to optimise intervention coverage.

DESIGN

To investigate these couples-level barriers and facilitiators, we conducted focus group discussions and in-depth interviews. Transcripts were analysed thematically and the interdependence model of communal coping and health behaviour change was adapted to explore factors impacting HIVST acceptability.

SETTING

We recruited pregnant women attending two public ANC clinics in Kampala, Uganda, and male partners of pregnant women between April 2019 and February 2020.

PARTICIPANTS

We conducted gender-stratified focus group discussions (N=14) and in-depth interviews (N=10) with pregnant women with and without HIV attending ANC, and male partners of pregnant women (N=122 participants).

INTERVENTION

We evaluated pregnant women's and male partners' perceptions of HIVST secondary distribution in Uganda, leveraging the interdependence model of communal coping and health behaviour change.

PRIMARY AND SECONDARY OUTCOME MEASURES

Key areas of focus included HIVST interest and acceptability, perspectives on HIV status disclosure to partners and gender roles.

RESULTS

Participants felt that predisposing factors, including trust, communication, fear of partner and infidelity, would influence women's decisions to deliver HIVST kits to partners, and subsequent communal coping behaviours such as couples HIV testing and disclosure. Pregnancy was described as a critical motivator for men's HIVST uptake, while HIV status of pregnant women was influential in couples' communal coping and health-enhancing behaviours. Generally, participants felt HIV-negative women would be more likely to deliver HIVST, while women with HIV would be more hesitant due to concerns about discovery of serodifference and relationship dissolution. Participants stressed the importance of counsellor availability throughout the process including guidance on how women should approach their partners regarding HIVST and post-test support in case of a positive test.

CONCLUSIONS

HIV-negative women in relationships with positive predisposing factors may be most likely to deliver HIVST and leverage interdependent coping behaviours. Women with HIV or those in relationships with negative predisposing factors may benefit from targeted counselling and disclosure support before and after HIVST kit distribution. Results can help support policy guidelines for HIVST kit distribution.

Making the Case for Joint Decision-Making in Future Multipurpose Prevention Technology (MPT) Choice: Qualitative Findings on MPT Attribute Preferences from the CUPID Study (MTN-045)

Introduction

Young women in sub‐Saharan Africa account for two‐thirds of all new HIV infections and face high rates of unintended pregnancy. Multipurpose prevention technologies (MPTs) are promising products under development that are designed to simultaneously prevent HIV and unintended pregnancy. Since MPTs will be used in the context of sexual relationships, ensuring acceptability and use requires understanding the role of male partners in MPT use decision‐making.

Methods

This paper draws on qualitative data from 39 couples enrolled in the Microbicide Trials Network (MTN) 045 study, conducted in 2019–2020. Partners completed a discrete choice experiment (DCE), first separately and then jointly, to measure preferences for future MPT attributes and then completed a qualitative interview. We also draw on quantitative data from interviewer observation about who dominated the decision‐making process during the joint DCE. Content analysis was used to examine (1) how couples made decisions on existing non‐MPT HIV and pregnancy prevention products; (2) how couples made decisions on future ideal‐MPT product during the DCE; and (3) how these decision‐making processes varied by decision‐making dominance (10 male, 10 female and 19 equal) and interview type (19 joint and 20 separate).

Results

Existing non‐MPT product decisions focused on trust between partners and product attributes, while future ideal‐MPT product decisions exclusively focused on product attributes. Across existing and future products, preferences for product attributes varied by gender. Male partners were most concerned with limiting side effects impacting sexual pleasure, female partners were most concerned with limiting side effects causing physical symptoms and both were concerned with the return to fertility. Across all dominance and interview types, couples reported making decisions together and female partners were often able to negotiate with male partners for their preferred product or set of product attributes.

Conclusions

Research activities in this study provided an opportunity for couples to openly present their product attribute preferences to their partner, learn about their partner's attribute preferences, negotiate for their ideal set of attributes and ultimately choose attributes that benefited the couple without disempowering the female partner. Future research should focus on the utility of couple‐based decision‐making aids or similar tools for facilitating joint MPT decision‐making.

HIV-serodifferent couples' perspectives and practices regarding HIV prevention strategies: A mixed methods study

A substantial proportion of heterosexually acquired HIV infections in the U.S. occur between partners in primary relationships characterized by mixed HIV status. The U.S. Centers for Disease Control and Prevention have issued guidelines prioritizing HIV-serodifferent couples for primary HIV prevention, including treatment-as-prevention and pre-exposure prophylaxis (PrEP). Yet, very little research has been conducted to understand the perspectives and practices of HIV-serodifferent couples regarding HIV prevention strategies in the U.S. To help fill this gap, we conducted a mixed methods study with 27 mostly Black/African American and Latinx HIV-serodifferent heterosexual couples residing in New York City to explore their knowledge, attitudes, practices, and perspectives regarding combination HIV prevention, including condoms, PrEP and viral control. All couples expressed the desire to maintain viral suppression in the HIV-positive partner, which was not always achieved. There was considerable heterogeneity in the use of HIV prevention methods by couples; and several patterns emerged that were largely driven by gender and relationship dynamics. Female partners, in particular, expressed high levels of anxiety around transmission of HIV and thus desired multiple methods of protection. Healthcare providers should consider couples' psychosocial well-being, relationship quality, and other motivational factors when helping to tailor HIV preventative care for mixed-status couples.

Social Influence and Uptake of Couples HIV Testing and Counselling in KwaZulu-Natal, South Africa

Social influences may create a barrier to couples HIV testing and counselling (CHTC) uptake in sub-Saharan Africa. This secondary analysis of data collected in the 'Uthando Lwethu' randomised controlled trial used discrete-time survival models to evaluate the association between within-couple average 'peer support' score and uptake of CHTC by the end of nine months' follow-up. Peer support was conceptualised by self-rated strength of agreement with two statements describing friendships outside of the primary partnership. Eighty-eight couples (26.9%) took up CHTC. Results tended towards a dichotomous trend in models adjusted only for trial arm, with uptake significantly less likely amongst couples in the higher of four peer support score categories (OR 0.34, 95% CI 0.18, 0.68 [7-10 points]; OR 0.53, 95% CI 0.28, 0.99 [≥ 11 points]). A similar trend remained in the final multivariable model, but was no longer significant (AOR 0.59, 95% CI 0.25, 1.42 [7-10 points]; AOR 0.88, 95% CI 0.36, 2.10 [≥ 11 points]). Accounting for social influences in the design of couples-focused interventions may increase their success.

Dyadic Coping in Couples Facing Chronic Physical Illness: A Systematic Review

Objective: Chronic physical illness affects not only patients but also their partners. Dyadic coping (DC)-the ways couples cope in dealing with a stressor such as chronic illness-has received increased attention over the last three decades. The aim of the current study was to summarize the state of research on DC in couples with chronic physical illnesses. Methods: We conducted a systematic review of qualitative, quantitative, and mixed-methods studies published between 1990 and 2020, assessing DC in couples affected by severe physical illnesses. We used DC and related search terms for the literature search in Psycinfo, Psyndex, and Medline. Five thousand three hundred thirty studies were identified in three electronic databases and 49 of these were included in the review (5,440 individuals reported on 2,820 dyads). We excluded studies on cancer, cardiovascular disease, and multiple sclerosis because of existing reviews in the respective fields. Half of the studies included were on diabetes. Other studies were on arthritis, chronic obstructive pulmonary disease (COPD), cystic fibrosis, human immunodeficiency virus (HIV), Huntington's disease, lupus erythematosus, Parkinson's disease, renal diseases, stroke, and endometriosis. Two raters extracted data using a predefined protocol, including study quality. Results were collated in a narrative synthesis organized by illness and DC operationalization. Results: Overall, DC was associated with beneficial outcomes in physical health, well-being, and relationship satisfaction. Differential effects became apparent for certain chronic conditions potentially depending on certain disease characteristics, such as early-onset, sudden-onset, or life-threatening conditions. Conclusion: Facing challenges together as a couple seemed indispensable for adapting to a diverse range of demands related to chronic illnesses with some specific demands of particular chronic diseases. There is a need for the development of truly dyadic interventions with an eye on the specific challenges of the various chronic conditions.

"We are in this together:" dyadic-level influence and decision-making among HIV serodiscordant couples in Tanzania receiving access to PrEP

BACKGROUND

A substantial number of new HIV infections in sub-Saharan Africa occur within stable couples. Biomedical prevention (pre-exposure prophylaxis, PrEP) and treatment (antiretroviral therapy, ART) can provide benefits to sexual partners and can be used to prevent infection within HIV serodiscordant couples. However, research is typically focused on individuals, not dyads, even when the intervention may directly or indirectly impact sexual partners. Gaps remain in understanding best practices for recruitment, informed consent, and intervention implementation in studies involving HIV prevention and treatment among heterosexual serodiscordant couples. This qualitative study was undertaken to understand and describe decision-making and dyadic-level influence among members of serodiscordant couples regarding (1) participation in a dyadic-based research study involving HIV self-testing and access to PrEP, and (2) utilization of PrEP and ART.

METHODS

This qualitative study was nested within an observational cohort study assessing the acceptability of home-based couples' HIV self-testing and uptake of dyadic care for serodiscordant couples involving facilitated referral for HIV-positive partners and access to PrEP for HIV-negative partners. Semi-structured in-depth interviews were conducted among a subset of study participants (n = 22) as well as individuals involved in serodiscordant relationships who chose not to participate (n = 9). Interviews focused on couples' decision-making regarding study participation and dyadic-level influence on medication use. Interviews were transcribed verbatim and translated from Kiswahili into English. Data were analyzed using thematic analysis.

RESULTS

Three major themes were identified: (1) HIV as "two people's secret" and the elevated role of partner support in serodiscordant relationships; (2) the intersectional role of HIV-status and gender on decision-making; (3) the relational benefits of PrEP, including psychosocial benefits for the couple that extend beyond prevention.

CONCLUSIONS

The study found that couples made joint decisions regarding study participation and uptake of HIV-related medication. Relational autonomy and dyadic-level influence should be considered within research and programs involving HIV serodiscordant couples.

A Dyadic Analysis of Criminal Justice Involvement and Sexual HIV Risk Behaviors Among Drug-Involved Men in Community Corrections and Their Intimate Partners in New York City: Implications for Prevention, Treatment and Policies

People in community corrections have rates of HIV and sexual risk behaviors that are much higher than the general population. Prior literature suggests that criminal justice involvement is associated with increased sexual risk behaviors, yet these studies focus on incarceration and use one-sided study designs that only collect data from one partner. To address gaps in the literature, this study used the Actor Partner-Interdependence Model with Structural Equation Modeling (SEM), to perform a dyadic analysis estimating individual (actor-only) partner-only, and dyadic patterns (actor-partner) of criminal justice involvement and greater sexual risks in a sample of 227 men on probation and their intimate partners in New York City, United States. Standard errors were bootstrapped with 10,000 replications to reduce bias in the significance tests. Goodness of fit indices suggested adequate or better model fit for all the models. Significant actor-only relationships included associations between exposures to arrest, misdemeanor convictions, time spent in jail or prison, felony convictions, lifetime number of incarceration events, prior conviction for disorderly conduct and increased sexual risk behaviors. Partner only effects included significant associations between male partners conviction for a violent crime and their female partners' sexual risk behaviors. Men's encounters with police and number of prior misdemeanors were associated with their own and intimate partners' sexual risk behaviors. Women's prior arrest was associated with their own and intimate partners' sexual risk behaviors. The results from the present study suggest that men on probation and their intimate partners' criminal justice involvement are associated with increased engagement in sexual risk behaviors. It is necessary to conduct greater research into developing dyadic sexual risk reduction and HIV/STI prevention interventions for people who are involved in the criminal justice system.

Testing strategies for couple engagement in prevention of mother-to-child transmission of HIV and family health in Kenya: study protocol for a randomized controlled trial

Background

HIV-related maternal deaths and HIV infection among infants remain unacceptably high across sub-Saharan Africa despite increased antenatal care attendance and provision of antiretroviral therapy to pregnant women. In the Jamii Bora (“Better Family” in Swahili) Study, we seek to test the efficacy of an interdependence theory-based couple intervention. The intervention reaches pregnant women and male partners through home visits by male-female pairs of lay health workers. The aim is to increase access to home-based couples’ HIV testing and counseling services to improve family health.

Methods

This is a three-arm randomized control trial among 1080 pregnant women 15 years of age or older, living with their male partners, and who have not undergone couples’ HIV testing and counseling in Kisumu and Migori Counties in Kenya. Couples will be randomized into three groups: home-based couple visits, HIV self-testing kits for couple use, or standard care (male partner clinic invitation letters). Participants will be followed up to 18 months postpartum. The study has three aims: in aim 1, we will determine the effects of the intervention on our primary outcome of couple HIV testing, compared to HIV self-testing kits and standard care; in aim 2, we will examine the intervention impact on HIV prevention behaviors, facility delivery, and postnatal healthcare utilization, as well as secondary health outcomes of maternal viral suppression and HIV-free child survival up to 18 months for couples living with HIV; and in aim 3, we will compare the cost-effectiveness of the home-based couple intervention to the less resource-intensive strategies used in the other two study arms. Assessments with couples are conducted at baseline, late pregnancy, and at months 3, 6, 12, and 18 after birth.

Discussion

The results from this study will inform decision-makers about the cost-effective strategies to engage pregnant couples in the prevention of mother-to-child transmission and family health, with important downstream benefits for maternal, paternal, and infant health.

Trial registration

ClinicalTrials.gov NCT03547739. Registered on May 9, 2018

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-020-04956-1.

Pathways for HIV Prevention Behaviors Following a Home-Based Couples Intervention for Pregnant Women and Male Partners in Kenya

Pregnancy is a time of heightened HIV risk, but also a phase when a couple can prioritize family health. We conducted secondary analysis of a home-based intervention in rural Kenya to explore couple-level adherence to HIV prevention behaviors. The intervention included health education, relationship-building skills, and Couples HIV Testing and Counseling. Pregnant women were randomized to the intervention (n = 64) or standard care (n = 63) along with male partners. Of 96 couples, 82 (85.0%) were followed to 3 months postpartum, when 31.0% of couples reported perfect adherence to HIV prevention. In logistic regression, intervention condition couples had three-fold higher odds of perfect adherence (AOR = 3.07, 95% CI = 1.01-9.32). A structural equation model found the intervention had moderate effects on couple communication, large effects on couple efficacy to take action around HIV, which in turn improved HIV prevention behaviors (CFI = 0.969; TLI = 0.955; RMSEA = 0.049). Strengthening couple communication and efficacy may help prevent the spread of HIV to infants or partners around the time of pregnancy.

The Influence of Shared or Separate Partner Residence on HIV Testing Among Latino Immigrants in the United States

BACKGROUND

The relationship context is influential in shaping HIV risk and preventive behaviors. Yet, there is little understanding about how shared or separate residence of partners shapes perceptions that affect HIV prevention.

METHODS

We explored how shared or separate residence from one's partner impacts HIV testing intentions among Latino immigrants in the USA. We analyzed data from 206 Latino immigrants residing in New York City, and examined three potential models to assess the relationships between partner residence, partner approval of HIV testing, and HIV testing behaviors.

RESULTS

Results indicated that shared residence was associated with greater partner approval to test for HIV (B = 0.48, 95% CI 0.01, 0.96, p = .04), and in turn, higher partner approval was associated with greater intention to test for HIV in the next 12 months (B = 0.38, 95% CI 0.15, 0.62., p < .01).

CONCLUSIONS

Results suggest the need to consider partner residency as an important factor in shaping determinants of HIV testing behaviors. Conceptualization of couples as living separately, across national borders, is warranted for couple-based health interventions given the current socio-political climate in the USA. Future research focused on couple-based HIV prevention should examine strategies and policies to preserve or strengthen partner dynamics among couples living apart.

Injecting-related trust, cooperation, intimacy, and power as key factors influencing risk perception among drug injecting partnerships

Sharing of injection drug use paraphernalia is a dyadic process linked to the transmission of HIV and hepatitis C virus (HCV). Despite this, limited research exists identifying specific dyadic interpersonal factors driving injecting partners' engagement in needle/syringe and ancillary injecting equipment sharing among young adults. Using semi-structured in-depth interview data collected between 2014 and 2015 from twenty-seven people who inject drugs (PWID), we applied an inductive approach to identify key injection drug-related interpersonal factors and developed a conceptual model integrating the findings based on interdependence theory. Interactions between injecting partners resulted in varying levels of injecting-related trust, cooperation, intimacy, and power. These factors interacted to collectively influence the type and level of risk perceived and enacted by injecting partners. The relationship between these injecting-related interpersonal factors, on the one hand, and risk perception on the other was dynamic and fluctuated between actions that protect the self (person-centered) and those that protect the partnership (partnership-centered). These findings indicate that the interpersonal context exerts substantial influence that shapes risk perception in all types of injecting partnerships. Partnership-focused prevention strategies should consider the dynamics of trust, cooperation, intimacy, and power, in characterizing dyadic risk perceptions and in understanding risky injecting practices among PWID.

Couple identity and well-being in Chinese HIV serodiscordant couples: resilience under the risk of stigma

Resilience literature has suggested the context-specific nature of resilience while such framework has yet to be expanded to health psychology research among HIV serodiscordant couples. Conceptualizing a couple affected by chronic diseases using a "we-ness" framework rather than two separate individuals is important for stress coping of the couple. Considering this social-cognitive context of couple coping would be helpful to facilitate resilience of both the patient and the spouse. It is not clear whether couple identity serves as a protective factor for HIV serodiscordant couples and whether stigma, a prevalent contextual risk in this population, will alter the strength of such a protective effect on well-being. This longitudinal study examined the protective effect of couple identity in predicting the psychological and physical well-being of HIV discordant couples and the moderating role of stigma in such associations. A total of 160 Chinese HIV serodiscordant couples completed the baseline survey and follow-up one year later. Results showed that couple identity predicted fewer depressive symptoms at both the within- and between-couple level and better self-rated physical health at the between-couple level one year later. These protective effects were diminished when HIV stigma was high. This study highlights the importance of examining resources with consideration of contextual factors. It also calls for the sensitivity of stigma in developing a couple-based intervention for HIV serodiscordant couples.

Couple-Level Dynamics and Multilevel Challenges Among Black Men Who Have Sex with Men: A Framework of Dyadic HIV Care

The primary romantic relationship may offer critical opportunities for improving HIV care among key populations affected by high rates of HIV infection and low rates of care engagement, such as black men who have sex with men. A conceptual framework is needed to identify dyadic processes involved in addressing challenges in retention in care and adherence to antiretroviral therapy. This study conducted dyadic and individual-level qualitative analyses of individual interviews with men living with HIV from 14 black gay couples (n = 28). Interviews explored each partner's perspectives on challenges to and supportive strategies for retention in care and medication adherence. Findings highlighted challenges at various levels of care engagement and patterns of dyadic interactions that impeded or facilitated HIV care. Couple-level processes (i.e., couple's resilience, interdependence) underlined a joint problem-solving approach toward addressing challenges in care engagement. Findings support a conceptual framework of dyadic HIV care that highlights the impacts of dyadic and individual factors on coordination of care and treatment to influence retention and adherence. The generalizability of study findings is limited by the small sample size. Implications for intervention design include leveraging drivers of partner support, including couples' resilience, in enhancing joint problem-solving in HIV care among black gay couples.

Marital infidelity, food insecurity, and couple instability: A web of challenges for dyadic coordination around antiretroviral therapy

RATIONALE

Despite the importance of primary partners for health, little is known about factors that constrain the ability of couples to work collaboratively towards HIV care and treatment (dyadic coordination). This study examined the interplay of marital infidelity, food insecurity, and couple instability on dyadic coordination and adherence to antiretroviral therapy (ART) in Malawi.

METHODS

In 2016, we conducted 80 in-depth interviews with 25 couples with at least one partner on ART. Couples were recruited at two HIV clinics in the Zomba district when attending clinic appointments. Participants were asked about their relationship history, relationship dynamics (love, trust, conflict), experiences with HIV care and treatment, and how partners were involved. Using an innovative analysis approach, we analyzed the data at the couple-level by examining patterns within and between couples.

RESULTS

Three patterns emerged. For some couples, ART led to positive changes in their relationships after men terminated their extramarital partnerships in exchange for love and support. For other couples with power imbalances and ongoing conflict, men's infidelity continued after ART and negatively affected dyadic coordination. Finally, some couples agreed to remain "faithful", but could not overcome stressors related to food insecurity, which directly impacted their adherence.

CONCLUSIONS

Couples-based interventions targeting ART adherence should improve relationship quality, while also addressing interpersonal stressors such as marital infidelity and food insecurity. Multi-level interventions that address both dyadic and structural levels may be necessary for couples with severe food insecurity.

Psychosocial and behavioural interventions towards HIV risk reduction for serodiscordant couples in Africa: A systematic review

BACKGROUND

Sexual transmission of HIV frequently occurs in the context of a primary relationship between two partners; however, HIV prevention interventions generally focus on individuals at risk, rather than specifying couples as a unit of change and analysis, neglecting the crucial role that partners may play in sexual behaviour. This article reviews published scientific literature addressing couple-oriented HIV counselling and testing and other behavioural interventions using an online search for peer-reviewed papers.

METHODS

A systematic review was conducted to evaluate what has been published on psychosocial interventions in HIV serodiscordant couples in Africa. Electronic databases were searched from January 1990 to December 2015. Quality assessment of included studies was conducted using the Systematic Appraisal of Quality in Observational Research tool.

RESULTS

The electronic database searches initially retrieved 493 records; after cross-referencing, removing duplicates and applying strict inclusion and exclusion criteria, only eight papers were included in this review. All the studies under review showed that couples-focused counselling and educational programmes were associated with positive outcomes including reduced HIV transmission, reduced unprotected sex, increased rates of status disclosure and high levels of treatment adherence.

CONCLUSIONS

The literature on interventions for HIV serodiscordant couples is sparse. However, most interventions indicate that couples-focused interventions are effective in HIV risk reduction. In spite of the limited available data and repeated recommendations by different health authorities, couple-centred approaches to HIV prevention have not been implemented on a large scale.

"We have heard it together": a qualitative analysis of couple HIV testing and counselling recruitment in Malawi's Option B+ programme

Encouraging HIV-infected pregnant women to recruit male partners for couple HIV testing and counselling (CHTC) is promoted by the World Health Organization, but remains challenging. Formal strategies for recruiting the male partners of pregnant women have not been explored within an Option B+ programme. Our objective was to learn about experiences surrounding CHTC recruitment within a formal CHTC recruitment study. A randomised controlled trial comparing two CHTC recruitment strategies was conducted among HIV-infected pregnant women presenting to Bwaila Antenatal Unit in 2014. Women were randomised to receive an invitation to attend the clinic as a couple or this invitation plus clinic-led phone and community tracing. A qualitative study was conducted with a subset of participants to learn about recruitment. This paper describes experiences of a subset of HIV-infected pregnant women (N = 20) and male partners (N = 17). One on one in-depth interviews were audio-recorded, transcribed, translated, and coded using content analysis. Nearly all women presented the invitation and disclosed their HIV-positive status to their partners on the day of HIV diagnosis, often to facilitate pill-taking. Men and women in both arms perceived the messages to be more compelling since they came from the clinic, rather than the woman herself. Couples who attended CHTC displayed greater care for one another and mutual support for HIV-related behaviours. Facilitating CHTC with invitations and tracing can support CHTC uptake and support for HIV-affected couples. In an Option B+ context, inviting partners for CHTC can facilitate male involvement and have important benefits for families.

The Role of the Primary Romantic Relationship in HIV Care Engagement Outcomes Among Young HIV-Positive Black Men Who Have Sex with Men

The primary romantic relationship plays a fundamental role in health maintenance, but little is known about its role in HIV care engagement among young Black men who have sex with men (MSM) living with HIV. We examined how HIV care engagement outcomes (i.e., having a primary healthcare provider, receiving HIV treatment, taking antiretroviral medication, and medication adherence) vary by partnership status (single vs. concordant-positive vs. discordant) in a sample of young Black MSM living with HIV. Results showed mixed findings. Partnership status was significantly associated with HIV care engagement, even after adjusting for individual, social, and structural factors. While partnered men were consistently more likely than their single counterparts to have a regular healthcare provider, to receive recent treatment, and to have ever taken antiretroviral medication, they were less likely to report currently receiving antiretroviral therapy. Moreover, men with a discordant partner reported better adherence compared to men with a concordant or no partner. The association between partnership status and HIV care engagement outcomes was not consistent across the stages of the HIV Care Continuum, highlighting the complexity in how and why young Black men living with HIV engage in HIV healthcare. Given the social context of HIV disease management, more research is needed to explicate underlying mechanisms involved in HIV care and treatment that differ by relational factors for young Black MSM living with HIV.

"Don't think I'm going to leave you over it": Accounts of changing hepatitis C status among couples who inject drugs

BACKGROUND

While the health-related benefits of intimate partnership are well documented, little attention has been paid to couples exposed to high levels of social stigma and exclusion. In this project we investigated an important site of stigma for partnerships by collecting accounts of changing hepatitis C (HCV) status ("sero-change") among couples that inject drugs. We explored what these accounts reveal about the meaning of HCV for these couples, and how this understanding contributes to our collective efforts at prevention and care.

METHODS

Drawing from a large dataset of qualitative interviews with couples, we focussed on those containing reports of sero-change. By adopting a methodology that positioned partnerships rather than individuals as the primary unit of analysis, we addressed the commonplace tendency to either overlook or discount as dysfunctional, the sexual relationships of people who inject drugs.

RESULTS

While some couples sought greater biomedical understanding as a means of coming to terms with sero-change, others drew on alternative logics or "rationalities" that sat firmly outside conventional biomedical discourse (privileging notions of kinship, for example). Regardless of which explanatory framework they drew on, participants ultimately prioritised the security of their relationship over the dangers of viral infection.

CONCLUSIONS

Effectively engaging couples in HCV prevention and care requires acknowledging and working with the competing priorities and complex realities of such partnerships beyond simply the identification of viral risk. The "new era" of direct acting antiviral treatments will provide ongoing opportunities to learn to integrate biomedical information within more socially sophisticated, relationally aware approaches.

The intimate relationship as a site of social protection: Partnerships between people who inject drugs

Public health research treats intimate partnerships as sites of risk management, including in the management of HIV and hepatitis C transmission. This risk-infused biomedical approach tends to undermine appreciation of the emotional and socially situated meanings of care in intimate partnerships. In this article we explore qualitative interview accounts of the care enacted in partnerships between people who inject drugs, drawing on a 2014 study of 34 couples and 12 individuals living in two locations of Australia. A thematic analysis highlights 'best friend relationships', 'doing everything together', 'co-dependency', and 'doing normalcy' as core to narratives of care. As we will argue, the accounts position the care undertaken by couples as at once shaped by day-to-day practices of drug use and by social situation, with the partnership enacting care as a form of social protection, including protection from stigma and other environmental hostilities. The intimacy of doing everything together offers insulation against stigma, yet also reproduces its isolating effects. While the care produced in drug-using partnerships is presented as double-edged, we note how interview accounts are used to deflect the charge that these relationships represent harmful co-dependency. Taken together, the interview accounts negotiate a 'counter-care' in relation to normalcy, presenting the intimate partnership between people who use drugs as a legitimate embodiment of care.

Discussing HIV Status: Is It Easier After 10 Years of Antiretroviral Treatment? The ANRS CO8 APROCO-COPILOTE Cohort

This study's objective was to explore the factors associated with the belief (or not) by people living with HIV that it is easier to talk about their seropositivity 10 years after initiating a protease inhibitor-containing ART. All patients in the ANRS CO8 APROCO-COPILOTE cohort who completed a self-administered questionnaire at 10 years of follow-up were included in this study. Forty-four percent of patients declared that discussing their seropositivity with their family was easier 10 years later, while 28 % declared this was true for discussing their status with a new sexual partner. Having a low socioeconomic status, not receiving social support from a steady partner and declaring a low number of discomforting symptoms 12 months after PI initiation were all independently associated with less difficulty in discussing seropositivity. This study highlights the difficulties in disclosing HIV 10 years after PI initiation, and the important influence of psychosocial factors and patients' daily-life experience on disclosure.

Couple interdependence impacts HIV-related health behaviours among pregnant couples in southwestern Kenya: a qualitative analysis

INTRODUCTION

HIV infection is frequently transmitted within stable couple partnerships. In order to prevent HIV acquisition in HIV-negative couples, as well as improve coping in couples with an HIV-positive diagnosis, it has been suggested that interventions be aimed at strengthening couple relationships, in addition to addressing individual behaviours. However, little is known about factors that influence relationships to impact joint decision-making related to HIV.

METHODS

We conducted qualitative in-depth interviews with 40 pregnant women and 40 male partners in southwestern Kenya, an area of high HIV prevalence. Drawing from the interdependence model of communal coping and health behaviour change, we employed thematic analysis methods to analyze interview transcripts in Dedoose software with the aim of identifying key relationship factors that could contribute to the development of a couples-based intervention to improve health outcomes for pregnant women and their male partners.

RESULTS

In accordance with the interdependence model, we found that couples with greater relationship-centred motivations described jointly engaging in more health-enhancing behaviours, such as couples HIV testing, disclosure of HIV status, and cooperation to improve medication and clinic appointment adherence. These couples often had predisposing factors such as stronger communication skills and shared children, and were less likely to face potential challenges such as polygamous marriages, wife inheritance, living separately, or financial difficulties. For HIV-negative couples, joint decision-making helped them face the health threat of acquiring HIV together. For couples with an HIV-positive diagnosis, communal coping helped reduce risk of interspousal transmission and improve long-term health prospects. Conversely, participants felt that self-centred motivations led to more concurrent sexual partnerships, reduced relationship satisfaction, and mistrust. Couples who lacked interdependence were more likely to mention experiencing violence or relationship dissolution, or having difficulty coping with HIV-related stigma.

CONCLUSIONS

We found that interdependence theory may provide key insights into health-related attitudes and behaviours adopted by pregnant couples. Interventions that invest in strengthening relationships, such as couple counselling during pregnancy, may improve adoption of beneficial HIV-related health behaviours. Future research should explore adaptation of existing evidence-based couple counselling interventions to local contexts, in order to address modifiable relationship characteristics that can increase interdependence and improve HIV-related health outcomes.

Harm reduction workers and the challenge of engaging couples who inject drugs in hepatitis C prevention

AIMS

Despite injecting-equipment sharing between sexual partners leaving them at increased risk of hepatitis C (HCV), there is scant literature available to guide harm reduction workers in their encounters with couples who inject drugs. This article explored workers' understandings of such couples and their accounts of working with them in relation to HCV prevention.

METHOD

Semi-structured interviews were conducted with 22 staff of harm reduction services located in Sydney and Melbourne, Australia.

RESULTS

Overall, staff represented couples as either absent from the service or as presenting with needs indiscernible from those of individual clients. Responses to questions about HCV and couples were framed primarily in terms of risk. Staff participants questioned 'genuineness' of clients' intimate relationships, instead characterising them as inauthentic and drug-driven. Working with couples was seen to present a number of organisational and clinical challenges. The benefits of recognising and working with such partnerships received scant acknowledgement. Rather, staff tended to perceive couples as being 'impenetrable' to health promotion messaging.

DISCUSSION

The framing and delivery of harm reduction in Australia remains an individualising enterprise with little capacity to recognise the intimate partnerships, including addressing the HCV risks specific to them. More effective harm reduction strategies may be achieved by transitioning to a practice framework that addresses the social context of injecting, including the experience of couples. This would require direct involvement of couples who inject drugs.

The effect of HIV counselling and testing on HIV acquisition in sub-Saharan Africa: a systematic review

OBJECTIVES

Annually, millions of people in sub-Saharan Africa (SSA) receive HIV counselling and testing (HCT), a service designed to inform persons of their HIV status and, if HIV uninfected, reduce HIV acquisition risk. However, the impact of HCT on HIV acquisition has not been systematically evaluated. We conducted a systematic review to assess this relationship in SSA.

METHODS

We searched for articles from SSA meeting the following criteria: an HIV-uninfected population, HCT as an exposure, longitudinal design and an HIV acquisition endpoint. Three sets of comparisons were assessed and divided into strata: sites receiving HCT versus sites not receiving HCT (Strata A), persons receiving HCT versus persons not receiving HCT (Strata B) and persons receiving couple HCT (cHCT) versus persons receiving individual HCT (Strata C).

RESULTS

We reviewed 1635 abstracts; eight met all inclusion criteria. Strata A consisted of one cluster randomised trial with a non-significant trend towards HCT being harmful: incidence rate ratio (IRR): 1.4. Strata B consisted of five observational studies with non-significant unadjusted IRRs from 0.6 to 1.3. Strata C consisted of two studies. Both displayed trends towards cHCT being more protective than individual HCT (IRRs: 0.3-0.5). All studies had at least one design limitation.

CONCLUSIONS

In spite of intensive scale-up of HCT in SSA, few well-designed studies have assessed the prevention impacts of HCT. The limited body of evidence suggests that individual HCT does not have a consistent impact on HIV acquisition, and cHCT is more protective than individual HCT.

Practices of partnership: Negotiated safety among couples who inject drugs

Despite the majority of needle-syringe sharing occurring between sexual partners, the intimate partnerships of people who inject drugs have been largely overlooked as key sites of both hepatitis C virus prevention and transmission, and risk management more generally. Drawing on interviews with 34 couples living in inner-city Australia, this article focuses on participants' accounts of 'sharing'. While health promotion discourses and conventional epidemiology have tended to interpret the practice of sharing (like the absence of condom use) in terms of 'noncompliance', we are interested in participants' socially and relationally situated 'rationalities'. Focussing on participants' lived experiences of partnership, we endeavour to make sense of risk and safety as the participants themselves do.How did these couples engage with biomedical knowledge around hepatitis C virus and incorporate it into their everyday lives and practices? Revisiting and refashioning the concept of 'negotiated safety' from its origins in gay men's HIV prevention practice, we explore participants' risk and safety practices in relation to multiple and alternative framings, including those which resist or challenge mainstream epidemiological or health promotion positions. Participant accounts revealed the extent to which negotiating safety was a complex and at times contradictory process, involving the balancing or prioritising of multifarious, often competing, risks. We argue that our positioning of participants' partnerships as the primary unit of analysis represents a novel and instructive way of thinking about not only hepatitis C virus transmission and prevention, but the complexities and contradictions of risk production and its negotiation more broadly.

Bidirectional links between HIV and intimate partner violence in pregnancy: implications for prevention of mother-to-child transmission

Introduction

Prevention of mother-to-child transmission (PMTCT) has the potential to eliminate new HIV infections among infants. Yet in many parts of sub-Saharan Africa, PMTCT coverage remains low, leading to unacceptably high rates of morbidity among mothers and new infections among infants. Intimate partner violence (IPV) may be a structural driver of poor PMTCT uptake, but has received little attention in the literature to date.

Methods

We conducted qualitative research in three Johannesburg antenatal clinics to understand the links between IPV and HIV-related health of pregnant women. We held focus group discussions with pregnant women (n=13) alongside qualitative interviews with health care providers (n=10), district health managers (n=10) and pregnant abused women (n=5). Data were analysed in Nvivo10 using a team-based approach to thematic coding.

Findings

We found qualitative evidence of strong bidirectional links between IPV and HIV among pregnant women. HIV diagnosis during pregnancy, and subsequent partner disclosure, were noted as a common trigger of IPV. Disclosure leads to violence because it causes relationship conflict, usually related to perceived infidelity and the notion that women are “bringing” the disease into the relationship. IPV worsened HIV-related health through poor PMTCT adherence, since taking medication or accessing health services might unintentionally alert male partners of the women's HIV status. IPV also impacted on HIV-related health via mental health, as women described feeling depressed and anxious due to the violence. IPV led to secondary HIV risk as women experienced forced sex, often with little power to negotiate condom use. Pregnant women described staying silent about condom negotiation in order to stay physically safe during pregnancy.

Conclusions

IPV is a crucial issue in the lives of pregnant women and has bidirectional links with HIV-related health. IPV may worsen access to PMTCT and secondary prevention behaviours, thereby posing a risk of secondary transmission. IPV should be urgently addressed in antenatal care settings to improve uptake of PMTCT and ensure that goals of maternal and child health are met in sub-Saharan African settings.

Engaging male partners in women's microbicide use: evidence from clinical trials and implications for future research and microbicide introduction

INTRODUCTION

Constructively engaging male partners in women-centred health programs such as family planning and prevention of mother-to-child HIV transmission has resulted in both improved health outcomes and stronger relationships. Concerted efforts to engage men in microbicide use could make it easier for women to access and use microbicides in the future. This paper synthesizes findings from studies that investigated men's role in their partners' microbicide use during clinical trials to inform recommendations for male engagement in women's microbicide use.

METHODS

We conducted primary and secondary analyses of data from six qualitative studies implemented in conjunction with microbicide clinical trials in South Africa, Kenya, and Tanzania. The analyses included data from 535 interviews and 107 focus groups with trial participants, male partners, and community members to answer research questions on partner communication about microbicides, men's role in women's microbicide use, and potential strategies for engaging men in future microbicide introduction. We synthesized the findings across the studies and developed recommendations.

RESULTS

The majority of women in steady partnerships wanted agreement from their partners to use microbicides. Women used various strategies to obtain their agreement, including using the product for a while before telling their partners, giving men information gradually, and continuing to bring up microbicides until resistant partners acquiesced. Among men who were aware their partners were participating in a trial and using microbicides, involvement ranged from opposition to agreement/non-interference to active support. Both men and women expressed a desire for men to have access to information about microbicides and to be able to talk with a healthcare provider about microbicides.

CONCLUSIONS

We recommend counselling women on whether and how to involve their partners including strategies for gaining partner approval; providing couples' counselling on microbicides so men have the opportunity to talk with providers; and targeting men with community education and mass media to increase their awareness and acceptance of microbicides. These strategies should be tested in microbicide trials, open-label studies, and demonstration projects to identify effective male engagement approaches to include in eventual microbicide introduction. Efforts to engage men must take care not to diminish women's agency to decide whether to use the product and inform their partners.